<form>
  <div class="efCheckout-column-left">

    <h4 class="column-notice">Account Information </h4>

    <div class="efCheckout-form-full">
      <label for="cardBrand_CC">Card Type</label>
      &nbsp;<span class="efCheckout-required">required</span> <br>
      <select id="cardBrand_CC" name="cardBrand_CC" onchange="ccTypeSelected('CC');">
        <option value="">Choose Card Type</option>

        <option value="American Express">American Express</option>


        <option value="Discover">Discover</option>


        <option value="MasterCard">MasterCard</option>


        <option value="Visa">Visa</option>


      </select>
    </div>



    <!-- Name on Card -->
    <div class="efCheckout-form-full">
      <div id="LCCHolderName_CC" style="display: block; visibility: visible;">
        <label id="labelCCHolderName_CC" for="CCHolderName_CC">
          Name on Card
        </label>
        &nbsp;<span class="efCheckout-required">required</span>
      </div>
      <span id="CCHolderNameContainer_CC">
        <input name="CCHolderName_CC" id="CCHolderName_CC" type="text" value="" style="display: block; visibility: visible;">
      </span>
    </div>

    <!-- Card Number -->
    <div class="efCheckout-form-full">
      <div id="LcardNumber_CC" style="display: block; visibility: visible;">
        <label id="labelCardNumber_CC" for="cardNumber_CC">Account Number</label>
        &nbsp;<span class="efCheckout-required">required</span>
      </div>
      <span id="cardNumberContainer_CC" style="display: block; visibility: visible;">
        <input type="text" value="" id="cardNumber_CC" name="cardNumber_CC" style="display: block; visibility: visible;">
      </span>
    </div>

    <!-- Card Card Expiry Month and Year -->
    <div class="efCheckout-form-full">
      <div id="cardExpiry_CC" style="display: block; visibility: visible;">
        <label>
          Expiration Date
          &nbsp;<span class="efCheckout-required">required</span>
        </label> <br>
      </div>
      <span id="LcardExpiry_CC" style="display: block; visibility: visible;">
        <select id="cardExpiryMonth_CC" name="cardExpiryMonth_CC" title="Expiration Month required" class="short-field">
          <option selected="selected" value="">Month</option>

          <option value="1">1</option>

          <option value="2">2</option>

          <option value="3">3</option>

          <option value="4">4</option>

          <option value="5">5</option>

          <option value="6">6</option>

          <option value="7">7</option>

          <option value="8">8</option>

          <option value="9">9</option>

          <option value="10">10</option>

          <option value="11">11</option>

          <option value="12">12</option>

        </select>
        <select id="cardExpiryYear_CC" name="cardExpiryYear_CC" title="Expiration Year required" class="short-field">
          <option selected="selected" value="">Year</option>

          <option value="2016">2016</option>

          <option value="2017">2017</option>

          <option value="2018">2018</option>

          <option value="2019">2019</option>

          <option value="2020">2020</option>

          <option value="2021">2021</option>

          <option value="2022">2022</option>

          <option value="2023">2023</option>

          <option value="2024">2024</option>

          <option value="2025">2025</option>

          <option value="2026">2026</option>

        </select>
      </span>
    </div>


    <!-- Security Code -->
    <div class="efCheckout-form-full">
      <div id="LcardPin_CC" style="display: block; visibility: visible;">
        <label id="labelCartPin_CC" for="cardPin_CC">Card Security Code</label>
        &nbsp;<span class="efCheckout-required">required</span> <br>
      </div>
      <div class="short-field-wrapper">
        <span id="pinContainer_CC" class="short-field" style="display: block; visibility: visible;">
          <input type="text" size="20" name="cardPin_CC" id="cardPin_CC" style="display: block; visibility: visible;">
        </span>
        <div id="WhatsThis_CC" class="short-field efCheckout-whats-this" style="display: block; visibility: visible;">
          <a id="WhatsThis_CCLink" href="javascript:void(0);">What's This?</a>
          <script type="text/javascript">
            // connect events to javascripts
            attachTooltipDialog(dojo.byId("WhatsThis_CCLink"), 'x_whatsthis');
          </script>
        </div>
      </div>
    </div>

    <div class="clear"></div>

  </div>
</form>